Preventing Surgical Site Infections in the Diabetic Cardiac Surgical Patient

1. Preventing Surgical Site Infections in the Diabetic Cardiac Surgical Patient Paula Pintar BSN, RN Alverno College – MSN Student Tutorial Project Spring 2010

2. Navigation of Tutorial This button will return you to the Tutorial menu screen. This button will return you to the previous slide. This button will advance you to the next slide. Click on any underlined word for additional information

3. Tutorial Menu Learning Objectives Stages of Surgical Wound Healing Activation of Stress Response And Surgery “Bundle” Elements & Nsg. Interventions Surgical Site Infection What is it? Age & Wound Healing Key Risks With Wound Healing Case Study Part 2 Why are Surgical Site Infections a Problem? Inflammation & Wound Healing Case Study Part 1 Tying It All Together Significance Of Diabetes Mellitus Genetics & Wound Healing Best Practice Standards “Bundle” References Click on the button you would like to view more information about.

4. Learning Objectives The Learner Will: Identify criteria used for classifying a surgical site infection (SSI). Identify why Surgical Site infections are a problem. Review of Diabetes Mellitus and the genetic link of incidence. Identify what risk factors can put Diabetic patients at a higher risk to developing a Surgical Site infection. Review the three main stages of wound healing: Inflammation, Proliferation, Remodeling. Be able to correlate the factors of Age, Inflammation, and the Generalized Stress Response in the diabetic patient; relate how these factors impact the stages of wound healing. Review Best Practice Standards and Nursing interventions for a Surgical Site infection prevention plan. Apply Nursing indicators to a case study. Understand how applying “best practice guidelines” will support positive outcomes for the patient, family, staff, health system, and community.

5. Surgical Site Infection (SSI)What Is It? Clinical and laboratory signs of infection at the surgical site within: 30 days of the surgery or Within 1 year if an implant was used (heart valve/joint) Criteria for Defining a Surgical Site Infection (SSI) Documented at various tissue levels: Superficial (skin/subcutaneous) Deep (soft tissue/muscle) Deep/organ space (organ space) Caused by: Endogenous bacteria – patients’ own skin flora Exogenous bacteria – environmental bacteria or surgical material Source: 1

6. SSI As Defined by the CDC • Superficial • Infection within 30 days after procedure • Involves the skin and subcutaneous tissue (and meets one of the following criteria) • Has purulent drainage • Organisms cultured from fluid or tissue • Displays at least 1 of the following pain, local swelling, redness, and incision is opened by surgeon • Diagnosis of superficial incision SSI by the surgeon or attending MD Source:1

7. SSI As Defined by the CDC • Deep Incisional SSI • Occurs within 30 days of procedure • 1 year if implant • Involves deep soft tissue ( fascial and muscle layers) • And patient displays at least one of the following • Purulent drainage • Spontaneously dehisces or opened by the surgeon and the patient has at least one of the following: • Fever, pain, abscess, or diagnosis by MD Source: 1

8. SSI As Defined by the CDC • Organ space • Occurs with in 30 days • 1 year if implant used • Includes any part of the body excluding skin, fascia, or muscle layer. • Must meet the following criteria • Purulent drainage from a drain that is place through a stab wound • Isolated organisms from an aseptic culture • Abscess • Diagnosis by MD Source: 1

9. Lets Review • What are the 3 tissue levels of a Surgical Site Infection? Deep Acute Organ Space Primary Superficial Scar

10. Surgical Site InfectionWhy Is It A Problem? • According to the Institute for Healthcare Improvement (IHI) • 38% of all Healthcare Associated Infections are SSI’s • 2 – 5% of patients operated on will develop an SSI • Developing an SSI will extend the hospital stay by 5 to 7 days • One SSI will increase cost by $2,734 - $26,019 (estimated on 1985 dollars) • Estimated national costs of 130 million to 845 million dollars spent a year on SSI’s. Source: 1

11. What Does this Mean at a Local Level? Higher cost related to longer stays Decreased patient turnover translates into less income for healthcare facility Healthcare facility develops a reputation of poor patient outcomes. Decreased reimbursement by The Centers for Medicare and Medicaid (CMS) as of October 1, 2008 stopped reimbursement for hospital acquired infections Microsoft clipart Source: 16

12. What Does this Mean at a Local Level? • Negative Outcomes Linked to SSI’s • Trend is toward public reporting of infection rates for healthcare facilities. • This will impact consumer decisions as to where they will go to have procedures performed. • Consumers have greater access to information - Intranet • Milwaukee has number of facilities with duplicative resources. Patients may begin shopping around for facility with lowest infection rates. Microsoft Clipart Source: 16

13. Lets Review • According to the Institute for Healthcare Improvement (IHI) 38% of all Healthcare Associated Infections are SSI’s. • Developing an SSI will extend the hospital stay by 5 to 7 days. • Increased reimbursement by The Centers for Medicare and Medicaid (CMS) as of October 1, 2008 started for hospital acquired infections. • Trend is toward public reporting of infection rates for healthcare facilities. True False True False True False True False

14. Lets take a closer look at a patient population (diabetes mellitus), and apply nursing indicators and medical knowledge to decrease and prevent the development of Surgical Site Infections. Now With The Problem Identified… Microsoft Clipart

15. Significance of Diabetes Mellitus Diabetes mellitus affects approximately 2.8 million people in the United States The disease is a metabolic process that results from a lack of insulin secretion or action. Insulin is a hormone that is secreted by the beta cells in the pancreas. This hormone then allows the cells in our body to absorb the glucose and convert it into energy to maintain metabolic processes. There are two main types of diabetes mellitus that the majority of diabetics are classified into. Microsoft Clipart Source: 6

16. Diabetes Mellitus & Genetic Link Type 1: This is characterized by an complete lack of insulin secretion and elevated blood sugar, related to destroyed pancreatic beta cells (6) Usually occurs at an early age (childhood) 5 to 10% of the diabetic population have this type of diabetes (~ 1 million people) (6) These individuals have been associated with an autoimmune link to the disease. (4) This autoimmune response is the cause of beta cell destruction (4) The other factor identified is an exposure to an environmental mediator, such as having an infection. (6) Microsoft Clipart Source: 4, 6

17. Diabetes Mellitus & Age Link Type 2 : This is characterized by having insulin resistance Approximately 90 to 95% of diabetics present with this type (~19 million people) 18 -20% of persons 65 and older have diabetes 40% have the disease or precursor to disease Obesity and older individuals is commonly associated with Type 2 There is multiple hypothesis as to the causal agents of this form. Due to the variability of the causal agents, it is difficult to predict or identify specific factors that lead to disease. It is known that autoimmune destruction of the beta cells, as in Type 1 does not occur. Microsoft Clipart Source: 6

18. Diabetes Mellitus & Link to Developing an SSI • Studies correlating elevated levels of hemoglobin A1C 6.5 (HgA1C) and uncontrolled blood sugars in the postoperative period have had a higher incidence of postoperative wound infections. • Blood glucose levels >200mg/dL in immediate postoperative period and up to 48 hours post operatively are a key link to SSI development. • Phagocyte activity is altered by the elevated blood glucose levels. Source: 6

19. Lets Review • What is the key reference data used to monitor blood sugar stability over time? K level Correct In Correct Amylase C reactive protein Hgb A1C Finger stick glucose Blood pressure Urine glucose

20. Review of the Surgical Wound Healing Process There are 3 main stages of wound healing 1. Inflammation 2. Proliferation 3. Remodeling Within each stage there is a complex system of cellular functions that occur. (5) Factors that can impede good wound healing are: Poor diet/uncontrolled blood sugars Compromised blood flow Disruption of inflammatory response Infection Effects of age (14) Microsoft Clipart Source: 5,14

21. Surgical Wound Healing Stages Stage 1 Inflammatory (acute) Incision – initial vasoconstriction followed by platelet aggregation to damaged endothelium (14) Followed by a dilation of capillaries Around 24 hours macrophages enter the area and remain there to clean up cellular debris and stimulate the healing process (5) Microsoft Clipart Source: 5,15

22. Surgical Wound Healing Stages Stage 2 – Proliferation 24-48 hours after wound occurrence the fibroblast and vascular endothelial cells begin formation (5) This is a fragile period for the wound due to new capillary growth (14) Then formation of new dermal layers begins (14) Microsoft Clipart Microsoft Clipart Source: 5,15

23. Review of Surgical Wound Stage 3 – Remodeling Occurs post wound by about week 3 Formation of a scar develops During this process the healing wound experiences a decrease in vascularization with the continuing development of scar tissue. Source: 14

24. Lets Review Stages of Wound Healing Stage Definition Inflammation New capillary growth Proliferation Wound stabilization Debris removal Remodeling Click on stage definition

25. Age & Wound Healing • Immunosenescence or age-related changes impact the immune system, putting these individuals at a higher risk for infection. • By age 50 the thymus gland has decreased in size. • The function of the helper T cells deteriorates • Which in turn prolongs the inflammation phase of wound healing. • During cardiopulmonary bypass blood cells are “bypassed” in normal circulation. This activates the cytokine response and activation of the phagocyte cells. Stages of Wound Healing Inflammation Proliferation Remodeling Microsoft Clipart Source:12

26. Inflammation & Wound Healing Stages of Wound Healing Inflammation Proliferation Remodeling • The key mediators in inflammation are Cytokines & Chemokines • These proteins activate the macrophages and lymphocytes. • Other contributing risk factors are high blood pressure, altered platelet function, systemic inflammation noted by elevated C-reactive protein. • There is a thickening of the blood vessel walls that supply nerves. This causes a decreased blood supply to tissues. • Elevated blood glucose levels cause damage to small blood vessels. In time this causes defects in the cell structure at the microcirculation level. Source: 14

27. Genetics & Wound Healing • Diabetes has the genetic disease link that contributes to poor wound healing. • Hyperglycemia will affect phagocyte function by lessening the chemotaxic and phagocytic action of the neutrophils. Source: 14 Microsoft Clipart

28. A Closer Look at the Generalized Stress Response (GSR), DM and SSI • During periods of stress such as surgery and anesthesia • There is an increase release of growth hormones • With this response there is a mobilization of fatty acids from the adipose tissue. • This decreases the cellular utilization of glucose causing a rise in blood glucose levels • During periods of stress, diabetic patients react with a variety of metabolic processes despite optimal insulin management Microsoft Clipart Source: 7

29. Review of the GSR • GSR – also known as “fight or flight response” • It is the sympathetic nervous system release of Catecholamine's: • epinephrine • adrenalin • The elderly individual has a slower response to epinephrine and it takes them longer to recover from its effects. • Excretion of these catecholamine's is also slower. • Lets take a closer look at what happens to blood sugar in response to stress response. (next slide) Source: 15

30. Action of the (GSR) Click on each object in order 1 Stress 2 Adrenal medulla Releases Epinephrine 3 Maintaining Blood Glucose is the Body’s goal 4 Liver releases glucose into blood 5 Release of fatty acid from the fat cells 6 Stops insulin release from beta cells Microsoft Clipart 7 Increasemuscle breakdown of glycogen stores 8 Decrease glucose movement into muscles Source: 15

31. Generalized Stress Response & DM The Diabetic patient experiencing stress will have added risk to SSI development Sporadic, transient increases of cortisol can affect blood sugar control There is an increased secretion of cortisolin response to stress, (it can cause damage to brain neurons over time) if the levels become too high. This is a Positive feedback system – an example of this is when an elderly person secretes cortisol in response to stress. Repeated exposure to the neurons causes the damaged. Therefore the neurons can no longer sense the level and the hypothalamus continues to secrete the hormone. To view graphic of Positive Feedback System, click HERE Source: 15

32. Graphic of Generalized Stress Response Positive Feedback System Source: 15

33. Wound Healing & Increased Risk of SSI Occurrence There is a 20% decrease in the dermal layer This translates into less strength and elasticity Blood vessels supplying the dermis are also more fragile These conditions translate into a decrease of vascular circulation with a decrease in oxygen delivery to the wound site. Elderly persons have stiffer arteries and narrower capillaries which will accentuate the effects of diabetes Stages of Wound Healing Inflammation Proliferation Remodeling Microsoft Clipart Source: 14

34. A Closer Look at the Who, What, and Why Of SSI Development • Early detection of infection is difficult as aged (65 or older) individuals present with atypical signs and symptoms: lack of elevated white blood cell count and temperature • Persons with diabetes mellitus have neuropathic and peripheral vascular disease which will impact circulation to the wound site. • Age is a predisposing factor resulting in decreased function of systems with an increased susceptibility to stressors. Stages of Wound Healing Inflammation Proliferation Remodeling Source:13

35. Case Study – Part 1 Lets apply this knowledge to a case study: 65 year old Caucasian, widowed female who is overweight (101 kg.) has a sedentary life style and lives alone. She has had poor medical care due to lack of financial resources. She thinks she recalls a doctor telling her in the past that she may have diabetes or “something.” The patient is now in the Cardiovascular Surgical Intensive care unit following surgery of a 4 vessel myocardial revascularization. Microsoft Clipart

36. Case Study – Part 1 Post operative day #1 Patient presents with the following: Elevated blood glucose for the last 4 assessments: 190, 200,207,195 Fatigue and difficult to arouse Low blood pressure :100/60 Sinus tachycardia: 120 bpm Urine output: 25-30cc/hr Low grade temperature: 99.1 blood temp Slight elevated white blood cell count: 11,000 Elevated C-reactive protein (CRP) level: 2 Decreased bilateral pedal pulses: + 1 Cool bilateral lower leg extremities: new on assessment Microsoft Clipart

37. Case Study – Part 1 Indicators that may lead to an SSI Diabetes Mellitus Inflammation Unstable blood sugars Fatigue Lack of family support Risk Factors of SSI? Low grade temperature Decreased pedal pulses Cool lower leg extremities Obesity GSR Age Temperature Sinus tachycardia Increased WBC Decreased urine output Increased CRP Click an indicators on the right to see what Physiological system they belong to.

38. Best Practice Standards – “Bundle” Elements • A “Bundle” is a group of researched based best practice interventions. • It is shown that when bundle elements are implemented together patient outcomes improve. Source: 2

39. Best Practice Standards – “Bundle” Elements Strict adherence to hand hygiene www.cdc.gov/handhygiene/Patient_Admission_Video.html Treat all remote infections to the elective surgical site prior surgery Do not shave hair at surgical site, but use clippers. This will cause less microabraisions to the skin. Control serum blood sugar levels, avoid hyperglycemic states. Recommend stopping tobacco use Antiseptic showers prior surgical procedure Use appropriate surgical skin prep Surgical team hand & forearm antisepsis Administration of appropriate antimicrobial prophylaxis drug at the correct time, and dose prior surgical incision (30min.) Source: 2

40. Bundle Elements & Nursing Interventions Pre-surgical baths have shown to decrease skin flora and multi-drug resistant bacteria (MDRO's) such as Methicillin resistant Staphaureus, vancomycin resistant Enterococci that may lead to surgical site infections. Most SSI’s are caused by the patients own bacterial flora 20% Staphylococcus aureus 14% Coagulase negative staphylococcus 12% Enterococci Source: 2

41. Bundle Elements & Nursing Interventions Glucose control intra-operative and postoperative (target less than 200 mg/dL) Unstable blood sugars affect the neutrophils ability to provide adequately functioning phagocytes Maintaining the postoperative dressing for 24-48 hours This is a critical time period when wound site is gaining stability in cellular repair and revascularization. Source: 10

42. Bundle Elements & Nursing Interventions Appropriate surgical antimicrobial prophylaxis given at: The appropriate time – 30 minutes prior cut time Provides a therapeutic blood & tissue level of antibiotic at time of surgery Appropriate dosage – weight based. Repeat dose if surgery extends past the ½ life of the drug Appropriate agent – for gram negative and gram positive organisms Discontinue antibiotic 24 hours post surgery – assists in decreasing resistance. Doses past 24 hour time frame of wound closure have not proven beneficial. Source: 1, 3

43. Bundle Elements & Nursing Interventions Clipping surgical site in place of shaving Eliminates micro abrasions to the skin that provides an entry portal for microorganisms Microsoft Clipart Source: 2

44. Bundle Elements & Nursing Interventions Maintain normothermia (greater that 36.0 Celsius) pre, intra, and postoperatively Decreases vasoconstriction in blood vessels. Normothermia will promote the blood flow and oxygen delivery to the cells Fosters immune function preservation If normothermia maintained produces less overall stress to diabetic patient Microsoft Clipart Source: 9

45. Let’s Review • Bundle elements produce better patient outcomes. • Application of bundle practices are researched based. • Using appropriate antibiotic therapy is a key bundle component. True False True False True False

46. What’s New?...Not Much! • Decreased emphasis and incentive for drug manufactures to develop new generations of antimicrobials to treat infections. • More deaths related to Methicillin-resistant Staphylococcus aureus (MRSA) in U.S. facilities than from HIV/AIDS & Tuberculosis combined. • Only 83 antibacterial in clinical trials – very small number in late stage testing • Only 5 pharmaceutical companies still support antibacterial programs. Source: 3

47. Antibiotic Manufacturing Strategies • Infectious Disease Society of America (ISDA) is working on a plan in cooperation with the pharmaceutical industry and academia to create and sustain research and a long term plan. • Incorporate big pharmacies, and small entities • Create incentives for pharmaceutical companies to participate in antibiotic research and development. Source: 3

48. Case Study – Part 2 Lets apply this knowledge to our case study: Post operative surgical day #3 Assessment findings: Blood Sugar range 185-220 over last 48hours Temp. 99.1-100.9(oral ranges) WBC 11,000 CRP level 3 Sternal incision warm, red, small opening at bottom draining creamy white fluid Wound culture showing Moderate PMS’s & Moderate colonies of Staphylococcus aureus Fatigues easily Stable SBP, Sinus tachycardia (105-110bpm), U.O. 30cc/hr Microsoft Clipart

49. Case Study – Part 2 Diabetes affect 2.8 million people in the United States. Identify three case study laboratory results that may be indicators of an SSI. Temperature, WBC, CRP, U.O., Positive wound culture, Fatigue What assessment finding is a response to activation of the Generalized Stress Response? Increased Heart Rate, Warm draining wound, Positive wound culture During cardiovascular revascularization surgery, what process causes a cytokine response? The process of “bypass”, anesthesia, maintaining normothermia In reference to question 3, what stage of wound healing is critical to a diabetic with uncontrolled blood sugars? Inflammation, Proliferation, Remodeling How is the proliferation stage of wound healing affected by diabetes? Microcirculation, cellular regeneration , decrease in metabolic needs What three nursing interventions can be initiated to help decrease the risk of patients developing an SSI? Hand Hygiene, Blood glucose control, Maintaining normothermia, quick ventilator weaning, frequent turning of patient

50. Tying It All Together • Surgical Site Infections affect patients, families, hospital systems, and communities. • They add to personal pain and suffering, mortality and financial burdens. • Research has identified that using the “Bundle” method of preventive measures is more effective in preventing SSI’s than when elements are applied inconsistently and individually. • Diabetics are at a higher surgical risk due to the inflammation correlation process of their disease.